Some of the largest payers now quietly pay a higher level office, ED, or hospital visit at the level below it. This is the neutral scoreboard: the documented cost of moving one E/M level down, at the local peer median in every state, built from Reddenda's index of public federal price-transparency filings. Then check your own remittances, on your own machine.
Every number below is a local peer median (P50) of commercial allowed amounts in that state, with the local P90 for context. The one level down column is the documented market gap between a level and the level beneath it. It is a modeled market benchmark, not your contracted rate, and not a claim that any payer downcoded any specific claim.
States ranked by the documented cost of paying a level 4 established office visit (99214) as a level 3 (99213), at the local peer median. Tap any state to load its full ladder above.
A downcode here is not automatically improper. When the record supports the lower level, the reduction can be correct. This is the market cost when it is not, and the reason it is worth checking.
Every item below is a real, public policy or regulator action, each with its source. We name a payer only where it has published the policy itself or a regulator has acted on the record.
Cigna's Evaluation and Management Coding Accuracy policy (R49) reviews professional claims billed with CPT 99204 to 99205, 99214 to 99215, and 99244 to 99245, and adjusts the service one level down for providers Cigna's records flag as coding higher than their peers for routine services. The lower level is paid first, and the original level is restored only after the full record is submitted and supports it.
Source: Cigna reimbursement policy R49 (PDF) · Cigna Provider NewsroomAetna's proprietary evaluation and management claim and code review program scrutinizes level 4 and 5 E/M claims and can pay them at a lower level. In late March 2025 it expanded from its initial pilot states to all Aetna commercial states except Louisiana (commercial only, not Medicare Advantage). The AMA formally resolved to oppose unilateral E/M downcoding, naming the Cigna and Aetna programs, and holds that it is never appropriate to downcode without a review of the medical record.
Source: Aetna E&M program document (PDF) · APMA · NBC NewsThe Maryland Insurance Administration issued a consent order (Case No. MIA-2026-03-009) with an $80,000 penalty, ordering Cigna to cease automatically reducing billed E/M code levels in Maryland and to reprocess affected claims back to October 1, 2025. On April 7, 2026 the MIA followed with Bulletin 26-9, extending the same prohibition to all health insurers and third-party payors operating in the state.
Source: ADA News · Becker's Payer · AMA state advocacy updateIndiana HEA 1271 defines downcoding as the unilateral alteration by an insurer of the payment for an E/M service code, and sets guardrails: downcoding must be clinically justified and transparent, a human must review the medical record, it cannot be based solely on diagnosis codes, and insurers cannot retroactively reduce reimbursement. A growing list of states has enacted or introduced similar downcoding disclosure and review laws.
Source: Indiana General Assembly, HB 1271 · LegiScanFor the full appeal-rights framework by plan type (ERISA, ACA, Medicare Advantage) and the payer remittance codes that flag a downcode, see the Downcode Radar overview. Regulatory context, not legal advice.
The index above is the market benchmark. Your electronic remittance (835 / ERA) is the record of what actually happened on your claims. In many files the payer reports the level you billed alongside the level it paid, and its own reason code for the change. Reddenda's on-device Downcode Radar reads every line and dollarizes it against these same local benchmarks.
Run your own remittances on your own machine. The files are parsed entirely in your browser. Nothing uploads, and no PHI ever reaches Reddenda.
SVC*HC:99213:25*220*44**1*HC:99214~ CAS*CO*150*34~
SVC06 is the code you billed (99214). SVC01 is the code they paid (99213). CARC 150 is the payer's own reason: the information submitted does not support this level of service. Most practices never read this field. The radar reads every line, in files you already have.
Drop a month of 835 files into the on-device Downcode Radar and see every documented and signaled downcode in your book, ranked payer by payer, dollarized against your state's published rates. Nothing uploads. No PHI leaves your browser. No BAA needed. Free to scan.
Methodology and sources. The index shows per-CPT percentiles of real published commercial contracted rates by state, from Reddenda's normalized dataset built on public federal Transparency in Coverage machine-readable files (45 CFR 147.210 and 147.212 require payers to publish and refresh them monthly), scoped to the selected state. Levels shown are the local peer median (P50) and local P90 of commercial allowed amounts. The one level down figure is the difference between a level's local median and the next lower level's local median in the same state, a market benchmark, not any single contract. The national view is the median of the state values across 52 jurisdictions. E/M families follow the current CPT structure, so the new patient ladder begins at 99202 (99201 was retired in 2021). Reference point: under the 2026 Medicare Physician Fee Schedule, a 99214 paid as a 99213 forfeits $40.42 per visit at the national non-facility rate. Cited facts: Cigna reimbursement policy R49 (effective October 1, 2025); Aetna proprietary E/M claim and code review program; American Medical Association E/M downcoding advocacy; Maryland Insurance Administration Consent Order MIA-2026-03-009 (March 13, 2026) and Bulletin 26-9 (April 7, 2026); Indiana HEA 1271 (effective July 1, 2026). Scope of the underlying index: 314M+ federal rate records, 500+ payers, 50 states, 9.2M+ NPIs, the live scope of the index:. All dollar figures are documented reimbursement opportunities or market benchmarks, modeled and not guaranteed; actual outcomes depend on payer response, contract terms, documentation, and appeal outcome. Naming a payer here reflects that payer's own published policy or a regulator's action on the record, and is not an assertion that any payer downcoded any specific claim. No PHI leaves the visitor's browser. Reddenda is not a law firm and nothing here is legal advice. © 2026 Reddenda / TwinFlame Group.